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PubMed2002

Bedside spirometry in a tertiary care hospital: the cleveland clinic experience.

BACKGROUND: In contrast to outpatient, laboratory testing, which is performed by a small, dedicated group of pulmonary function technologists, inpatient, bedside spirometry at the Cleveland Clinic Hospital is performed less frequently and by a larger group of respiratory therapists with broader responsibilities. A 1998 audit of bedside spirometry tests at our hospital showed that American Thoracic Society acceptability and reproducibility criteria were infrequently met (15% of instances). METHODS: To address that shortcoming, we initiated an improvement plan for bedside spirometry that included: (1) A didactic review of American Thoracic Society acceptability and reproducibility criteria that was videotaped and reviewed by all but one of the therapists performing spirometry; (2) limiting the number of operators to a "core group" to allow more tests per therapist; (3) producing printouts of the pulmonary function tests, which allows immediate review of volume-time and flow-volume curves; (4) central review of all tests by a pulmonary function technologist and feedback and constructive suggestions on test quality and reproducibility to operators. After initiating the program we performed a consecutive survey of all inpatient spirometry sessions performed from July 16, 1998, to March 2, 1999. RESULTS: During the survey period, 63.5% of the tests (n = 137) were deemed acceptable, exceeding the low baseline rate of 15% (p < 0.001). Values for forced expiratory volume in the first second were reproducible in 83.9% of sessions. Values for forced vital capacity were reproducible in 80.3% of sessions. CONCLUSION: A quality improvement program for bedside spirometry testing that emphasizes training and routine feedback on test quality can enhance the quality of inpatient spirometry testing.

Clinical Competence↗

PubMed2005

Barriers to the use of spirometry in general practice.

BACKGROUND: Guidelines advise chronic obstructive pulmonary disease (COPD) should be diagnosed and managed by using spirometry to demonstrate irreversible airflow limitation and monitor change in smokers and ex-smokers aged over 35 years. METHODS: A cross-sectional study of patients and their general practitioners investigating use of spirometry in COPD in two practices by lung function assessment, review of practice records, interviews and focus groups. RESULTS: Sixteen GPs, and 38 patients with a diagnosis of COPD participated. At diagnosis, although 72% had spirometry, this occurred in only 41% of 17 patients diagnosed by a GP; but in all 19 cases when a specialist was involved. Diagnosis often occurred late, despite all patients having previously recorded symptoms typical of COPD. General practitioners expressed a preference to diagnose COPD on clinical grounds. Although 58% of patients had recent spirometry for current management, only 32% were performed by their GP. There were organisational and technical barriers to spirometry and poor recognition of the essential role of spirometry in the diagnosis of COPD. DISCUSSION: There are a number of potentially reversible factors that hinder practice recommendations regarding the use of spirometry in general practice to diagnose and manage COPD.

Aged↗

PubMed2005

Risk factors for prevalence of and mortality related to restriction on spirometry: findings from the First National Health and Nutrition Examination Survey and follow-up.

OBJECTIVE: To define risk factors for both restriction on spirometry and subsequent mortality in a national cohort of US adults. METHODS: Participants in the First National Health and Nutrition Examination Survey (NHANES I) were followed for up to 22 years. Subjects were classified using the forced expiratory volume in one second (FEV1), the forced vital capacity (FVC), and the FEV1/FVC ratio into subgroups with and without restriction on spirometry. Regression models were developed to determine risk factors for restriction on spirometry and death. RESULTS: Our final cohort consisted of 4320 subjects, of whom 481 (10.3 weighted %) had restriction on spirometry. The largest risk factors for restriction on spirometry were a cardiothoracic ratio of >55% (OR 4.3, 95%CI 3.1-5.9), race other than black or white (OR 3.7, 95%CI 1.8-7.8), and a history of stroke or paralysis (OR 1.8, 95%CI 1.1-2.9). The overall mortality rate was increased in subjects with restriction on spirometry (25.7 vs. 10.3 deaths per 1000 person-years). CONCLUSIONS: Restriction on spirometry is associated with comorbid disease and increased mortality, and is present in a significant proportion of the population.

Adult↗

PubMed1991

AANA journal course: new technologies in anesthesia: update for nurse anesthetists--monitoring ventilation and compliance with Side Stream Spirometry.

A new anesthesia technology, Side Stream Spirometry, now allows clinicians to monitor pressure, volume, flow, compliance, and resistance during routine anesthesia practice. Continuous monitoring with Side Stream Spirometry is a major adjunct to patient safety because numerical and visual references show how change in one respiratory parameter affects the mechanics of the entire breath cycle. To optimize ventilation and ensure adequate oxygenation, it is common practice for clinicians to verify that the proper volume per breath is being delivered to the patient at the lowest possible pressure. For artificial ventilation to be most physiologic, each breath must be delivered with the most appropriate flow, at the required volume, under the pressure appropriate for each patient's pulmonary system, and at the correct respiratory breath rate. Side Stream Spirometry makes it possible to continuously measure lung mechanics and the gas dynamics of flow, volume and pressure. Using a simple sensor, the D-lite, Side Stream Spirometry is compatible with all common models of anesthesia machines, ventilators and breathing circuits. Side Stream Spirometry measures all parameters closest to the patient, at the tracheal tube or mask. This sensor location provides actual patient information which is not altered by the volume of gas compressed in the breathing circuit, the absorber system, or in the bellows of the ventilator. This installment of the AANA Journal Course will discuss the technology of Side Stream Spirometry and its application to monitoring pulmonary ventilation. Clinical evidence of ventilatory changes will be graphically demonstrated using the CAPNOMAC ULTIMA, a respiratory gas monitoring system, equipped with Side Stream Spirometry.

Airway Resistance↗

PubMed1989

Preoperative spirometry before abdominal operations. A critical appraisal of its predictive value.

Preoperative spirometry is commonly ordered before abdominal surgery, with the goal of predicting and preventing postoperative pulmonary complications. We assessed the evidence for this practice with a systematic literature search and critical appraisal of published studies. The search identified 135 clinical articles, of which 22 (16%) were actual investigations of the use and predictive value of preoperative spirometry. All 22 studies had important methodological flaws that preclude valid conclusions about the value of screening preoperative spirometry. The available evidence indicates that spirometry's predictive value is unproved. Unanswered questions involve (1) the yield of spirometry, in addition to history and physical examination, in patients with clinically apparent lung disease; (2) spirometry's yield in detecting surgically important occult disease; and (3) its utility, or beneficial effect on patient outcome. Spirometry's full potential for risk assessment in the individual patient has not yet been realized.

Abdomen↗

PubMedDate not supplied

The use of helium-oxygen spirometry in occupational lung disease.

One of the major problems in the study and management of occupational lung disease is to detect early impairment so that corrective measures can be taken before irreversible or more severe damage occurs. Unfortunately standard spirometric tests are not sensitive to functional impairment in small airways where the earliest abnormalities in many pulmonary diseases are thought to occur. A a result, several new tests have been devised in the last decade to study this so-called silent zone. Helium-oxygen spirometry, one such test, is safe, convenient, and can eaily be added to conventional air spirometry apparatus. Two studies using helium-oxygen and air spirometry done by the Appalachian Laboratory are presented. In the first, non-exposed controls were compared to flax workers with either low or high dust exposure. Both air and helium-oxygen flow volume curves showed decreased flow rates after a work-shift in the high exposure group but no change in controls. In the low-dust exposure group, only helium-oxygen spirometry detected decreased post-shift flow rates suggesting small airways disease. Coal miners were compared to controls in the second study. Subgroups of younger subjects, smokers, non-smokers, bronchitics, and non-bronchitics were also analyzed. In no case did helium-oxygen spirometry detect differences which were not present on routine air spirometry. It is concluded that further studies in this area are needed. At present, random screening with helium-oxygen spirometry for early occupational disease is not warranted, and this test remains an investigative tool.

Epidemiologic Methods↗

PubMed2004

Spirometry and peak expiratory flow in the primary care management of COPD.

Spirometry is essential for the diagnosis of chronic obstructive pulmonary disease (COPD). In patients with COPD the decline in lung function is usually so slow that spirometry is unlikely to provide significantly new information more than every 1-2 years. However, it is useful to have an objective measure of lung function in the assessment of acute exacerbations of COPD and in the assessment of treatments. Peak expiratory flow (PEF) has been dismissed by national and international guidelines as an inappropriate test for the assessment of the impact of COPD, but with poor evidence in support of this position. This seems short-sighted since PEF is a reliable and reproducible test and could contribute to the management of COPD in the short term and in support of spirometry. As a result of infection or in response to treatment there may be changes in airway calibre in COPD which could be captured in the consultation by PEF. In a primary care setting spirometry is too time consuming and complex to be provided in the context of normal acute consulting. Furthermore there is no evidence that spirometry provides more information than PEF in the day-to-day management of a patient already diagnosed with COPD using forced expiratory volume in the first second/forced vital capacity (FEV1/FVC). Primary care teams should ensure that their patients have adequate access to high quality spirometry. This can be provided in primary care or in local centres or in hospitals depending on the interest, motivation and resources of primary care teams. In support of spirometry general practitioners (GPs) should then consider using PEF in the day-to-day management of COPD.

Journal Article↗

PubMed2026

Effects of Adding Incentive Spirometry to Hospital-Based Cardiovascular Rehabilitation on Pulmonary Complications, Hospital Length of Stay, and Clinical-Functional Recovery After Cardiac Surgery: A Randomized Controlled Trial.

BACKGROUND AND PURPOSE: This study investigated the effects of combining incentive spirometry with cardiac rehabilitation compared with cardiac rehabilitation alone on postoperative pulmonary complications, clinical-functional recovery, and hospital length of stay in patients undergoing cardiac surgery. METHODS: Randomized controlled trial was conducted from May 2019 to October 2023 in two hospitals, including 46 inpatients undergoing cardiac surgery. Participants were assigned to incentive spirometry plus cardiac rehabilitation or cardiac rehabilitation alone. Both interventions were performed twice daily; spirometry used a volume-oriented device, and rehabilitation followed a seven-step protocol (2-4 METs). Outcomes included postoperative pulmonary complications, functional capacity (6-min walk test), handgrip strength, respiratory muscle function, and length of hospital stay. RESULTS: The incentive spirometry associated with cardiac rehabilitation group had a longer extracorporeal circulation time (98 ± 26 min) than the cardiac rehabilitation group (76 ± 1; p = 0.008). Both groups showed a postoperative decline in respiratory muscle strength, and walking distance (MD: -64.37 m; 95% CI: [-24.1; -104.6]; d = 0.71), with no difference in postoperative pulmonary complications and handgrip strength. The incentive spirometry associated with cardiac rehabilitation group did not significantly differ on postoperative hospital stay compared with the cardiac rehabilitation group (MD: -1 day; 95% CI: [-4.71; 2.71]; d = -0.19). CONCLUSIONS: In this study, no additional benefit was observed with the addition of incentive spirometry to cardiac rehabilitation compared with cardiac rehabilitation alone. No significant differences were detected between groups in postoperative pulmonary complications, hospital length of stay, or clinical-functional recovery among individuals undergoing cardiac surgery. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (REBEC) under the number RBR-8tsjf97.

Aged↗

PubMed2004

Guideline for office spirometry in adults, 2004.

OBJECTIVE: To provide clinical guidelines for office spirometry in South Africa. OPTIONS: More stringent guidelines are required for diagnostic laboratories and research. OUTCOMES: To minimise variations in standard practice and improve the quality and usefulness of spirometry in the clinical setting. EVIDENCE: Recommendations are based on key international publications as well as research publications regarding reference values for South Africans. BENEFITS, HARM AND COSTS: The medical, social and economic benefits and costs of standardisation of office spirometry in South Africa were considered in the recommendations. VALIDATION: The document has been reviewed and endorsed by the South African Thoracic Society. CONCLUSIONS: The indications for spirometry must be specific and clear. Spirometry equipment must meet internationally accepted performance standards and carry proof of validation. Equipment must be regularly calibrated and maintained. Individuals performing spirometry must be adequately trained and demonstrate a high level of competence. Subject preparation, testing and quality control of results must be carried out according to published guidelines. Finally, test results must be interpreted according to current diagnostic guidelines, taking into account the purpose of the test, appropriateness of reference values and the clinical evaluation.

Adult↗

PubMed1995

Exercise oximetry versus spirometry in the assessment of risk prior to lung resection.

BACKGROUND: Spirometry remains a standard method of assessing patient risk prior to lung resection despite its poor sensitivity and specificity. This study compares the relative ability of standardized exercise oximetry and spirometry--forced expiratory volume in the first second--to predict morbidity and mortality after lung resection. METHODS: The study comprised a retrospective review of 396 consecutive patients of whom 299 underwent both oximetry and spirometry. Oximetry was undertaken during standard exercise under the supervision of a single physical therapist. Spirometry identified 46 patients with a forced expiratory volume in the first second of less than 1.5 L who were considered to be high risk. Exercise oximetry was used to identify patients with arterial oxygen desaturation at rest, while walking on level ground, or while climbing two flights of stairs (n = 65). RESULTS: Compared with spirometry, exercise oximetry more reliably predicted home oxygen requirements (p < 0.001), need of admission to the intensive care unit (p < 0.05), prolonged hospital stay (p < 0.001), and respiratory failure (p < 0.05). Oximetry identified 50% of the patients who died, all of whom had a forced expiratory volume in the first second of greater than 1.5 L. Despite its superior predictive value, the sensitivity of oximetry remained low. CONCLUSIONS: We conclude that standardized exercise oximetry is a superior screen of the high-risk patient than spirometry (forced expiratory volume in the first second) prior to pulmonary resection when there are no other risk factors noted on initial history and physical examination. A prospective, randomized trial is required to substantiate this conclusion.

Critical Care↗

PubMed2000

Controversies in the use of spirometry for early recognition and diagnosis of chronic obstructive pulmonary disease in cigarette smokers.

Office spirometry used to detect COPD in smokers ages 44 and above with respiratory symptoms probably meets the criteria for a population-based screening test and for clinical case finding: If not detected early, COPD causes substantial morbidity or mortality, and smoking cessation is more effective when COPD is recognized before exertional dyspnea develops. Office spirometry is a feasible testing strategy and may be used to encourage smoking cessation efforts that change behavior in at least some patients. Office spirometry is relatively simple and affordable, is safe, and includes an action plan with minimal adverse effects. On the other hand, the false-positive and false-negative rates of office spirometry in the primary care setting may be higher than diagnostic spirometry performed during epidemiologic studies or in diagnostic pulmonary function laboratories, and the incremental benefit of office spirometry on smoking cessation rates is poorly established (when added to referral to an AHCPR-based smoking cessation program).

Adult↗

PubMed1995

Incentive spirometry to prevent acute pulmonary complications in sickle cell diseases.

BACKGROUND: This study was designed to determine the incidence of thoracic bone infarction in patients with sickle cell diseases who were hospitalized with acute chest or back pain above the diaphragm and to test the hypothesis that incentive spirometry can decrease the incidence of atelectasis and pulmonary infiltrates. METHODS: We conducted a prospective, randomized trial in 29 patients between 8 and 21 years of age with sickle cell diseases who had 38 episodes of acute chest or back pain above the diaphragm and were hospitalized. Each episode of pain was considered to be an independent event. At each hospitalization, patients with normal or unchanged chest radiographs on admission were randomly assigned to treatment with spirometry or to a control nonspirometry group. Each patient in the spirometry group took 10 maximal inspirations using an incentive spirometer every two hours between 8 a.m. and 10 p.m. and while awake during the night until the chest pain subsided. A second radiograph was obtained three or more days after admission, or sooner if clinically necessary, to determine the incidence of pulmonary complications. Bone scanning was performed no sooner than two days after hospital admission to determine the incidence of thoracic bone infarction. RESULTS: The incidence of thoracic bone infarction was 39.5 percent (15 of 38 hospitalizations). Pulmonary complications (atelectasis or infiltrates) developed during only 1 of 19 hospitalizations of patients assigned to the spirometry group, as compared with 8 of 19 hospitalizations of patients in the nonspirometry group (P = 0.019). Among patients with thoracic bone infarction, no pulmonary complications developed in those assigned to the spirometry group during a total of seven hospitalizations, whereas they developed during five of eight hospitalizations in the nonspirometry group (P = 0.025). CONCLUSIONS: Thoracic bone infarction is common in patients with sickle cell diseases who are hospitalized with acute chest pain. Incentive spirometry can prevent the pulmonary complications (atelectasis and infiltrates) associated with the acute chest syndrome in patients with sickle cell diseases who are hospitalized with chest or back pain above the diaphragm.

Acute Disease↗

PubMed2005

The effect of spirometry and exercise on exhaled nitric oxide in asthmatic children.

American Thoracic Society (ATS) guidelines recommend to refrain from spirometry or exercise before measuring fractional exhaled nitric oxide (FENO) because forced breathing maneuvers might influence FENO values. However the few studies already reported in children have given conflicting results. The aim of the study was to observe to what extent spirometry or exercise could affect FENO in asthmatic children. Twenty-four asthmatic children (mean age 12.8 yr) were enrolled. Measurements of FENO were performed before and 5, 15, 30, 45 and 60 min after spirometry or a 6-min walk test, on two separate days in random order. Geometric mean FENO at baseline was 25.6 parts per billion (ppb) before spirometry and 23.5 ppb before exercise. A small drop of FENO to 24.2 and 23.7 ppb was found 5 and 15 min after spirometry (both p = 0.04). After exercise, FENO values showed a larger drop to 18.5 ppb after 5 min and 20.7 ppb after 15 min (p < 0.001; p = 0.004 respectively). Changes in FENO occurred after exercise irrespective of baseline FENO and values returned to baseline within 30 min. We conclude that both spirometry and exercise affect FENO in asthmatic children. As the changes after exercise may lead to erroneous interpretations, children should refrain from physical exercise during at least 30 min before FENO measurements.

Adolescent↗

PubMedDate not supplied

Underdiagnosis of chronic obstructive pulmonary disease: a rationale for spirometry as a screening tool.

Chronic obstructive pulmonary disease (COPD) is associated with significant morbidity and mortality. It is the fourth leading cause of death in the United States, and its impact on quality of life can be severe. The debate on spirometry as a screening tool has been raised and dropped on various occasions over the past 30 years. This paper readdresses the debate in the light of recent evidence from population studies. Spirometry is an underused, easy to perform office-based procedure that has been further facilitated by the advent of modern technology. Despite the fact that spirometry is the gold standard for the diagnosis and assessment of COPD, mass screening using this tool remains controversial. This article provides a discussion based on a recent review of the literature regarding the current and future status of spirometry as a screening tool. A thoughtful approach to spirometry screening should include assessments of the magnitude of underdiagnosis, potential effectiveness of intervention, predictive value of spirometry and clinical profile of patients with COPD.

Humans↗

PubMed2003

Economic issues in the use of office spirometry for lung health assessment.

The National Lung Health Education Program (United States) has recently recommended using office spirometry to screen for subclinical lung disease in adult smokers. No published studies evaluate the economic consequences of this recommendation. This review article outlines the issues that must be considered when evaluating the costs and health benefits of office spirometry. Much of the available data on the effectiveness of screening is from studies that included smoking cessation interventions, making it difficult to determine the effects of screening alone. The sensitivity and specificity of screening spirometry are not known, but may not be important in the economic model, because even false positive test results are beneficial if they lead to smoking cessation. Costs to be considered include those of spirometry itself, of implementing and maintaining screening and smoking cessation programs, and of their consequences, ie, reduced morbidity (lower short term health care costs) and mortality (perhaps higher long term health care costs). Despite these unique challenges, data are available to perform economic analyses regarding screening spirometry. Such analyses should play a role in future clinical policy making. Even modest quit rates attributable to screening spirometry may result in highly favourable cost effectiveness ratios.

Adult↗

PubMedDate not supplied

Can access to spirometry in asthma education centres influence the referral rate by primary physicians for education?

BACKGROUND AND OBJECTIVES: Asthma remains uncontrolled in a large number of asthmatic patients. Recent surveys have shown that a minority of asthmatic patients are referred to asthma educators. The objective of the present study was to assess the influence of increased access to spirometry in asthma education centres (AECs) on the rate of patient referrals to these centres by general practitioners. METHODS: A one-year, prospective, randomized, multicentric, parallel group study was conducted over two consecutive periods of six months each, with added spirometry being offered in the second six-month period to the experimental group. Ten AECs were enrolled in the project. An advertisement describing the AECs' services was sent by mail to a total of 303 general practitioners at the start of each period, inviting them to refer their patients. Measures of the frequency of medical referrals to the AECs were assessed for each period. RESULTS: The group of AECs randomly selected for spirometry in the second six-month period received 48 medical referrals during the first period and 32 during the second one, following proposed spirometry. AECs that had not offered spirometry received five referrals during the first period and seven during the second period. One AEC withdrew a few weeks after the study began and others encountered administrative problems, reducing their ability to provide interventions. CONCLUSIONS: Referral to AECs is not yet integrated into the primary care of asthma and offering more rapid access to spirometry in the AECs does not seem to be a significant incentive for such referrals.

Asthma↗

PubMed1992

Postthoracotomy respiratory muscle mechanics during incentive spirometry using respiratory inductance plethysmography.

We undertook this study to characterize the postthoracotomy compartmental displacement and respiratory mechanical changes occurring during and after the performance of the incentive spirometry maneuver. We also evaluated the effect of recumbency angle on compartmental recruitment. Sixteen patients were randomized to perform incentive spirometry either at 30 degrees or 60 degrees recumbency angle. They were studied using respiratory inductance plethysmography to measure tidal volume, respiratory frequency, inspiratory time, rib cage motion/tidal volume ratio, inspiratory duty cycle, and inspiratory flow. Patients were studied before surgery and on postoperative days 1 and 3. Statistical analysis was accomplished using multiple measures ANOVA with post-hoc Student's t-tests when appropriate. Preoperative incentive spirometry augmented VT by increasing both VT/TI and TI. Postoperatively, the incentive recruitment of VT was reduced, a result of a decrease in TI and TI/TTOT; VT/TI was unchanged. There was postoperative decrease of AB and AB/VT during incentive spirometry, greatest in the 60 degrees group. Our results characterize the nature of the respiratory recruitment afforded by incentive spirometry, before and after thoracotomy. We also found evidence of postthoracotomy diaphragmatic derecruitment during incentive spirometry exacerbated by a high recumbency angle.

Female↗

PubMed2005

Airway narrowing measured by spirometry and impulse oscillometry following room temperature and cold temperature exercise.

STUDY OBJECTIVE: The efficacy of using impulse oscillometry (IOS) as an indirect measure of airflow obstruction compared to spirometry after exercise challenges in the evaluation of exercise-induced bronchoconstriction (EIB) has not been fully appreciated. The objective was to compare airway responses following room temperature and cold temperature exercise challenges, and to compare whether IOS variables relate to spirometry variables. DESIGN: Spirometry and IOS were performed at baseline and for 20 min after challenge at 5-min intervals. SETTING: Two 6-min exercise challenges, inhaling either room temperature (22.0 degrees C) or cold temperature (- 1 degrees C) dry medical-grade bottled air. At least 48 h was observed between these randomly assigned challenges. PARTICIPANTS: Twenty-two physically active individuals (12 women and 10 men) with probable EIB. INTERVENTIONS: Subjects performed 6 min of stationary cycle ergometry while breathing either cold or room temperature medical-grade dry bottled air. Subjects were instructed to exercise at the highest intensity sustainable for the duration of the challenge. Heart rate and kilojoules of work performed were documented to verify exercise intensity. MEASUREMENTS AND RESULTS: Strong correlations were observed within testing modalities for post-room temperature and post-cold temperature exercise spirometry and IOS values. Spirometry revealed no differences in postexercise peak falls in lung function between conditions; however, IOS identified significant differences in respiratory resistance (p < 0.05), with room temperature-inspired air being more potent than cold temperature-inspired air. CONCLUSIONS: Correlations were found between spirometric and IOS measures of change in airway function for both exercise challenges, indicating close equivalency of the methods. The challenges appeared to elicit the EIB response by a similar mechanism of water loss, and cold temperature did not have an additive effect. IOS detected a difference in degree of response between the temperatures, whereas spirometry indicated no difference, suggesting that IOS is a more sensitive measure of change in airway function.

Adult↗